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Practice Guidelines for Type 2 Diabetes Mellitus

Foreword
Preface

Acknowledgements

CONTENTS

1. SCREENING FOR DIABETES MELLITUS
1.1 Preamble
1.2 Objective
1.3 Strategy
1.4 Target Group
1.5 Who Should be Screened
1.6 Schedule
1.7 Centre For Screening
1.8 Screening Test
1.9 Process And Procedure For Screening

2. MANAGEMENT PLAN FOR TYPE 2 DIABETES (NIDDM) AND IGT
2.1 Education
2.2 Diet Therapy
2.3 Exercise

3. MEDICATION
3.1 Indication
3.2 Oral Hypoglycaemic Agents (OHA)
3.3 General Guidelines For Use of OHA in Diabetes

4. INSULIN
4.1 Indication
4.2 Insulin Therapy in Type 2 Diabetes (NIDDM) - Pregnancy
4.3 During Stress and Emergency
4.4 General Guidelines For Use of Insulin in Diabetes

5. MANAGEMENT OF CHRONIC DIABETIC COMPLICATIONS
5.1 Introduction
5.2 Type of Complications
5.3 Early Detection and Treatment of Diabetic Complications
5.4 Retinopathy
5.5 Nephropathy
5.6 Neuropathy
5.7 Diabetic Foot
5.8 Macrovascular Complications

REFERENCES

APPENDICES

Appendix 1 Definition of Terminology
Appendix 2 Procedure For Fasting Plasma Glucose (FPG)
Appendix 3 Procedure For Oral Glucose Tolerance Test
Appendix 4 Procedure For Use of Glucose Meter
Appendix 5 Diagnostic Values For The Oral Glucose Tolerance Test (OGTT)- WHO
Criteria
Appendix 6 Food Pyramid For Diabetes
Appendix 7 Implementation of Diabetes Care Programme
Appendix 8 Checklist For Screening of Diabetes Mellitus At Primary Care Level.
Appendix 9 Visual Acuity and Fundoscopy Examination.
Appendix 10 Examination of The Foot
Appendix 11 Body Mass Index (BMI) and Waist-Hip Ratio (WHR)
Appendix 12 Clinical Monitoring Protocol
Appendix 13 Biochemical Monitoring Protocol

FOREWORD

TAN SRI DATO' (DR.) ABU BAKAR SULEIMAN

FRACP, M. Med. (S'pore), MBBS (Mon.), AM,
FACP (Hon.), FRCPI, FRCSI (Hon.), FRCSE (Hon.), FAMS,
FRCP (Glas.), FRCPE, AMP (Harvard).

KETUA PENGARAH KESIHATAN MALAYSIA
(DIRECTOR GENERAL OF HEALTH MALAYSIA)

Diabetes is one of the most prevalent chronic diseases among Malaysians. It is also well
known that more than half of diabetic cases will eventually develop pathological changes
in end organs. This will have a profound debilitating effect on the productivity and
quality of life. Hence it is imperative that the Ministry of Health has to devote more care
and attention towards diabetes so as to prevent its implications.

The proper diagnosis and control of diabetes is therefore essential. Appropriate skill in
detecting diabetic complications and updated knowledge in the management of this is
absolutely important.

The development of this guideline by The Ministry of Health with the help of Malaysian
Diabetes Association is indeed very timely. It is our ardent hope that this guideline will
assist doctors and paramedics in the profession to provide proper care and management
of diabetic cases. I would take this opportunity to congratulate the task force who worked
diligently to make this available. A note of special thanks to the contributors from
universities, NGOs and the Ministry of Health.

TAN SRI DATO' (DR) ABU BAKAR SULEIMAN

DIRECTOR GENERAL OF HEALTH MALAYSIA

PREFACE

Professor Dato Dr Anuar Zaini Md Zain
President Malaysian Diabetes Association
Dean, Faculty of Medicine,
University of Malaya.

Diabetes Care is not the domain of any particular group of the health professionals. It
provides a good example where an integrated and holistic approach to chronic disease
management can increase efficiency and reduce health cost. It has been clearly
demonstrated that the economic losses can be greatly reduced by investing in promotive
and preventive programs particularly with regards to early detection of disease and
prevention of complications.

It is estimated that there will be a 3-fold increase in the prevalence of diabetes among
Asians by from the current estimates of 50 million people. Malaysians will probably see a
prevalence exceeding 10% by the year 2020. At the same time the demographic change
with a more elderly population the cost will escalate tremendously.

It is therefore, vital that Diabetes Care be co-ordinated properly and systematically at all
levels of health care team. This consensus on practice guidelines on the management of
Type 2 diabetes is an updated version of the first documentation in 1991. It represents the
teamwork where doctors, dieticians and nurses were involved in the round table
discussions for both versions. This updated edition provides a more comprehensive
approach focusing on treatment strategies.

With the recent international agreement on the proper nomenclature for the various types
of diabetes, it is suggested that this be included in this document. The term Type 2
diabetes, as it is now officially called, reflects the actual disease entity irrespective
whether they require or depend on insulin or not. Diabetes mellitus is a complex disease
and the heterogeneity in its clinical presentation, genetic predisposition and end-organ
complications make it utterly important to approach its management in a concerted
pattern enabling future meaningful evaluation. Any change of treatment strategies will
then be justified and supported.

I would like to take this opportunity to thank everyone involved in developing this
guidelines and particularly members of the task force team for their untiring effort to
make this 'joint venture' successful.

Prof Dato Dr. Anuar Zaini
Chairman,

Practice Guidelines Taskforce

. In 1995.3 mmol/L) c) Pregnant women should be screened at least once at > 24/52 period of gestation. lethargy. 1. pruritus vulvae. It is estimated that about 95% of diabetes patient have type 2 diabetes mellitus.3 STRATEGY Selective .) * Family history of diabetes mellitus * Hypertension * Hyperlipidaemia (Total cholesterol > 6. 1. b) Any person who presents to a primary care facility for any reason.SCREENING FOR DIABETES MELLITUS 1.5 mmol/L and fasting triglyceride >2.7% of the adult population suffer from diabetes mellitus. without symptoms of diabetes. the National Cardiovascular Risk Factor Prevalence Study showed that 7. polyphagia.1 PREAMBLE Types 2 Diabetes Mellitus (NIDDM) is a major public health problem in Malaysia. polydipsia.2 OBJECTIVE To assess specific high risk population groups for detection of diabetes and ensure timely and appropriate management. Recognizing that late diagnosis will lead to complications of diabetes. This disease is common in all ethnic groups especially among Indians.Opportunistic Screening. a good screening programme will prevent or delay the onset of complications and resulting morbidity. balanitis) must be screened.4 TARGET GROUP High risk individuals who present themselves to a health medical facility. polyuria. 1.5 WHO SHOULD BE SCREENED a) Any person found to have symptoms of diabetes mellitus (weight loss. tiredness. The first step towards effective care is to ensure an early diagnosis. 1. but has any ONE of the following features should be screened: * Age 35 years or older * Obesity (BMI ³ 30 and above) * History of Gestational Diabetes Mellitus * History of big baby (Birth Weight 4.0 kg.

8 SCREENING TEST Random Blood Glucose (capillary blood) using meters and strips by trained personnel (refer to Appendix 4) 1. Practitioners' Clinics 5.1. . Hospitals 1.7 CENTRE FOR SCREENING 1. Outpatient clinics 2. Community Health Clinics (Klinik Desa) 4.9 PROCESS AND PROCEDURE FOR SCREENING Refer to Figures 1 and 2. General. Health clinics 3.6 SCHEDULE Table 1: Schedule of the Screening Programme With one or more risk factors Annually Age 35 to 40 years without any Every 2 years risk factor Age >= 40 years Annually 1.

Figure 1: Screening Process for Diabetes Mellitus at Primary Care Level .

Figure 2: Procedure for Screening and Diagnosing Diabetes Mellitus and Impaired Glucose Tolerance. .

diet therapy and exercise must be reinforced .MANAGEMENT PLAN FOR TYPE 2 DIABETES (NIDDM) AND IGT Three main approaches are recommended for the newly diagnosed type 2 diabetes (NIDDM) and IGT patient as illustrated in figure 3. Figure 3: Management Plan for Type 2 Diabetes (NIDDM) and IGT Health education.

c. . There is chronic hyperglycaemia together with other metabolic abnormalities. The majority of them are symptomatic. 2. Risk factors for diabetes e. weight loss. Currently there is no known cure but the disease can be controlled enabling the person to lead a healthy and productive life. The Disease a. tiredness. polydipsia.2. It is a common chronic disorder b.1 Education Figure 4: Education Strategies Information checklist: 1. Common symptoms : polyuria. The role of insulin resistance and/or deficiency d. Symptoms of the disease 50% of the cases are not aware that they are diabetic.

swimming. • Importance of high fibre . Diet 3. headache. low salt diet. 4. cycling .2. low fat. and nerves 3. Exercise 4. three times per week . Polyuria. Signs and Symptoms Acute Warning Signs Hyperglycaemic coma Severe thirst. carbohydrate. drowsiness Hypoglycaemic coma Hunger. tremor. stair/hill climbing jogging. tiredness. aggressive behaviour 2. lipid level and blood pressure • helps to control body weight • improves cardiovascular fitness • feeling of well being 4.1 Benefits of diet • Control of weight. sweating. vitamin and minerals. tennis etc. brisk walking. vomiting. Individualize diet intake accordingly to achieve and maintain reasonable bodyweight and optimal glycaemic and lipid control. At least 30 minutes. fats. kidneys. 3. heart. blood vessels.1 Chronic Complications Damage to end-organs such as eyes.2 Types of exercise • Aerobic exercise e. high complex carbohydrate.g.2 Type of diet • Balanced diet with adequate amounts of proteins.1 Acute Complications: Table 2: Acute Diabetes Complications.3 Distribution of Food Intake Distribute food intake evenly throughout the day. blood glucose and lipid levels 3.1 Benefits of exercise • Improves and control glycaemia.

Insulin Used in those with uncontrolled diabetes and during acute complications and pregnancy • Note: (i) to (iii) oral medication. • Any other exercise recommended for healthy living 4.g.g. (i) and (iii) not known to cause hyperglycemia Emphasize appropriate dose.3 Precaution • Seek your doctor’s advice before initiating any exercise program. This include • Blood glucose monitoring • Body weight monitoring • Foot care • Personal hygiene • Healthy lifestyle . It allows the patient to assume responsibility and control of his/her own diabetes management. • Exercise must be individualized. Self care Self care improves motivation and compliance. unless symptomatic or if the blood glucose remains high. Sulphonylureas e. Medication should be given after an adequate trial of diet and exercise. Biguanides e. metformin delay absorption and increase peripheral utilization of glucose ii. • If blood glucose is > 20 mmol/l . N. timing in relation to meals and compliance 6. acarbose reduces glucose absorption from the gut iv. Expected decrease in blood glucose is around 20%. Medication Emphasize that diet and exercise are the mainstay of treatment. glicazide Stimulate insulin secretion from pancreas and improve insulin action iii. α-glucosidase inhibitors e.B Certain patients can control their diabetes with diet and exercise alone 5. control diabetes first before starting exercise. 4 groups of drugs i. glibenclamide.g. glipizide.

2.2 Diet Therapy Figure 5: Diet Therapy Figure 6: Food Pyramid for Diabetes .

age and choice. jogging. How much to exercise?: Exercise should be done regularly and correctly It should balance the amount of food we eat. tennis or badminton. swimming. Common types of brisk walking. Type of exercise: The kind of exercise to choose depends on individual physical condition. An exercise should be sufficient to cause sweating and raise the pulse rate to 120 to 150 beats per minute. control diabetes first before starting exercise 1. 2. For most people 30 minutes of exercise should be enough. cycling.2. skipping. Daily exercise is preferred. It must be enjoyable and be capable of being incorporated into daily living. Exercise should be carried out 3 to 4 times a week in order to be effective. stairs climbing. aerobic exercise.3 Exercise Figure 7: Exercise Strategies NB If blood glucose is > 20 mmol/L. .

unassisted golf 400 intermediate cycling. running. refer to Tables 3 and 4. of general movements and stretching exercises. Any exercise regime should include the following: • First Phase 10 minute warming up in the form. jogging Very Hard 5 soccer. swimming. medical and physical fitness including glycaemic status should be assessed. swimming . Table 3: ENERGY EXPENDITURE Kcal/hr Intensity Types of Exercises 60 minimal at rest 300 moderate walking. How To Exercise? Before starting on an exercise programme. This routine should be strictly adhered to in order to avoid and minimise injury.3. gardening. tennis 600 strenuous squash. types and level of physical activity. For energy expenditure. fast walking Hard 10 climbing stairs or hills. • Second Phase 20 to 30 minutes of exercise proper. shopping Moderate 20 cycling at level surface. hill climbing Table 4: Types and Levels of Physical Activity Level Duration Types of Physical Activity (min) Mild 30 slow walking. • Third Phase 5 to 10 minutes of cooling down including stretching.

Compliance with • Diet • exercise • medication. f. When indicated. Assessment of understanding of diabetic education given previously. polydipsia and weight loss or • asymptomatic and blood glucose levels are very high (above 20 mmol/L) on 2 occasions. Additional medications must not be encouraged to merely cover extra intake of food.4 months) between increments. Duration of trial therapy with diet and exercises alone to control diabetes is usually three months but it is variable and depends on patient compliance and response to the therapy. while re-emphasising diet and exercise. OHAs are not recommended for diabetes diagnosed in pregnancy as they are not proven to be safe. b.2. such as infections and myocardial infarction. should be given to allow achievement of a steady state.1 Indication Oral hypoglycaemic agents (OHA) should only be used after adequate trial of therapy with prudent diabetic diet. e. Fructosamine. An appropriate duration of time (2 . exercises and healthy life style. the following aspects should be taken into account before deciding on further treatment:-: a. Oral Hypoglycaemic Agents (OHA) Oral Hypoglycaemic agents (OHA) used in Type 2 diabetes (NIDDM) currently belong to 3 different types . Changes in body weight. Alleviation of symptoms.MEDICATION 3. polyuria. Blood glucose (taking into account the timing and amount of food taken and medication at the time of the blood test). Oral drugs may be required without waiting for response to diet and exercises in patients who are • very symptomatic with thirst. d. start with a minimal dose of OHA. OHAs are usually not the first line therapy in diabetes diagnosed during situations of stress. since insulin therapy is usually given. HbA1 or HbA1c. c. At each treatment review . 3.

• Metformin and sulphonylurea. Maximum dose 850 mg twice daily Caution: • Not recommended in elderly patients (>70 years) • Must not be used in patients with impaired renal function (creatinine > 300 mol/L).0 g three times daily. • Sulphonylureas can be combined with metformin.3. Maximum dose 1. • Sulphonylureas should be taken 30 min before a meal. (slow release formulation) Usual dose 850 mg daily. congestive cardiac failure. have synergistic effect to further reduce blood glucose.2. acarbose or insulin to improve control if indicated.2. • Second generation sulphonylureas restore first phase insulin secretion postprandially and reduce basal insulin and therefore less hypoglycaemia and less weight gain.1 Biguanides • Biguanides do not stimulate insulin secretion. respiratory impairment. 3.2. • If serum creatinine increases. recent myocardial infarction. by increasing insulin sensitivity at the tissues and by reducing hepatic glucose production. It can lower plasma glucose by up to 20% and is useful as first line drug treatment in the obese. The side effects can be further reduced by taking it with food. liver cirrhosis. vascular disease and severe infections or any conditions known to cause lactic acid accumulation. stop the drug. • Vitamin B12 deficiency may occur if metformin is given to patients who have had partial gastrectomy and terminal ileal disease. • Metformin-SR. Metformin can increase insulin sensitivity and reduce insulin requirements • Metformin dosage Initial dose 500 mg daily increasing to 500 mg twice daily in one week to reduce gastrointestinal side effects. Usual therapeutic dose 500 mg three times daily. and probably lowers glucose by increasing tissue utilization of glucose. . They can lower plasma glucose by up to 25%. Sulphonylureas • Sulphonylureas lower plasma glucose by increasing insulin secretion by the islet cells of pancreas.

. -glucosidase inhibitors • -glucosidase inhibitors (e. • Glibenclamide is metabolised by the liver but its metabolites are active and excreted by the kidneys. Administration of drugs that can displace them (e. acarbose).g. • Sulphonylureas are contraindicated in patients known to be allergic to sulpha drugs. 3. NSAIDs and blockers) can thus increase the risk of hypoglycaemia. Second generation sulphonylureas (Gliclazide and Glipizide) are purely metabolised by the liver and may still be used in renal impairment. • Side effects with sulphonylureas are rare and include hepatitis.g.5 mg OM 10 mg BD Medium (Daonil. SIADH. act at the gut epithelium. antithyroid drugs. The risk is higher in the presence of renal impairment or liver cirrhosis or the use of long acting preparations in the elderly. anticoagulants. • Sulphonylurea drugs are mostly protein bound. Caution: • Sulphonylureas cause hypoglycaemia because they increase insulin secretion. Table 5: Currently available Sulphonylureas and the respective recommended dosage: Drugs Minimum dose Maximum dose Duration Tolbutamide 500 mg TDS 1 gm TDS short (Rastinon) Chlorpropamide 125 mg OM 500 mg OM very long (Diabinese) Glibenclamide 2. blood dyscrasia.2. They do not cause hypoglycaemia. The dose must be reduced in renal impairment.3. sulpha drugs. to reduce glucose absorption by inhibiting the -glucosidase enzymes.5 mg OM 10 mg BD short • Chlorpropamide and tolbutamide are purely excreted by the kidneys and are contraindicated in renal impairment. • -glucosidase inhibitors decrease postprandial glucose surge. Euglucon) Gliclazide 40 mg OM 160 mg BD short (Diamicron) Glipizide (Minidiab) 2. • Sulphonylureas should be avoided in the obese because they cause increased appetite and weight gain.

They can have synergistic effects when used with metformin and sulphonylureas. sulphonylurea drug can be started.3 General Guidelines for Use of OHA in Diabetes • For non obese patient who could not be controlled on diet and exercise. such as glibenclamide or glipizide or glicazide. . • In elderly obese subjects. Acarbose can be safely used. the drug of choice is a second generation sulphonylurea at moderate dose. Acarbose is an acceptable alternative as first line therapy. metformin is a drug of choice. The patient should be monitored for renal impairment. Sulphonylureas can be combined with metformin and/or acarbose to improve control if indicated. insulin may be started. the drug of choice is a small dose of glicazide or glipizide and metformin must be avoided • In patients with complications. Dosage Initial dose 50 mg/day and increase only in the absence of gastrointestinal symptoms Usual dose 50-100 mg during main meals 3. Targets for control are less stringent because of increased risk of hypoglycaemia but metformin is to be avoided. They can also be used in combination with insulin. • For obese patient who could not be controlled on diet and exercise. • They are useful particularly in those with normal fasting glucose levels and raised postprandial glucose levels. If diabetes is still not well controlled. glipizide. For those who still could not be controlled on metformin and/or acarbose. sulphonylureas such as glicazide. Diet and exercise must be re-emphasised. a sulphonylurea can be started but long acting drugs are to be avoided. Diet and exercise must be reemphasised. glibenclamide should be started. • In elderly non obese subjects. Acarbose can also be safely used.

Figure 8: Medication for obese type 2 diabetes (NIDDM) .

Figure 9: Medication for non-obese type 2 diabetes (NIDDM) .

1 Indications: Short term use • acute illness. • surgery. hyperosmolar non- ketotic coma. • pregnancy. • breast-feeding or • severe metabolic decompensation (Diabetic ketoacidosis.INSULIN 4. lactic acidosis. severe hypertriglyceridemia • Long term use • treatment failures despite maximal dose of oral drugs and non-pharmacological regimens. • Figure 10: Insulin therapy in Type 2 Diabetes (NIDDM) .

Figure 11: Oral Hypoglycaemic Agents (OHA) Failure .

Bedtime Insulin Daytime Sulphonylurea 4.Figure 12: Insulin Therapy in OHA failure Note: FPG . .2 INSULIN THERAPY IN TYPE 2 DIABETES (NIDDM) – PREGNANCY These are recommendations for women with NIDDM who are planning pregnancies.Fasting Plasma Glucose BIDS .

who require > 2. OHA therapy should be replaced by insulin.g. consider long-term insulin therapy. infection.3 DURING STRESS AND EMERGENCY • OHA may not be adequate in controlling glycaemia during stress and emergency (e. • If patient developed DKA during the stress and the patient is young.Pre-Pregnancy • counseling is important: • pregnancy should be planned • glycaemic control before pregnancy. Patient may develop DKA during stress • Patient can be put back on their OHA regime when stress is resolved.5 mg glibenclamide or its equivalent before conception should remain on insulin • Metformin is contra-indicated • It is recommended that women identified should be referred to the Physician for further management. post meal plasma glucose levels weekly. pre-meal. • All patients requiring GIK (glucose insulin potassium) therapy should be referred for hospital administration . myocardial infarction and surgery) • In any form of stress. 4. • Glucose-Insulin-K regime can be used during delivery/LSCS Post-partum • In breast-feeding mothers. aim for normal HbA1c (< 7%) • insulin therapy may be necessary before pregnancy During Pregnancy: • Achieve and maintain normal glucose levels • close monitoring required (frequency of monitoring is individualised) • FPG. • fructosamine (fortnightly) • HbA1c (6 .12 weekly) • insulin therapy if dietary therapy fails.

• GIK regime can be continued until normal oral intake after surgery . incorrect dosing.0 units/kg body weight. full insulin therapy may be considered at the beginning.4 General Guidelines for Use of Insulin in Type 2 Diabetes • Pancreatic failure in type 2 diabetes (NIDDM) is mainly a clinical judgement. Control with insulin or OHA as indicated.0 taking orally post-op once taking orally Poor control Stop OHA FPG > 8. because of the risk of inducing hypoglycaemia in the early hours in the morning. once taking orally • If elective surgery. • All insulin treated patients must be taught to recognise symptoms of hypoglycaemia and its management.m.m. his/her lifestyles and other associated medical problems and medications especially those that affect insulin sensitivity. insulin/c-peptide estimations) is not critical but should be obtained whenever possible. delay operation if diabetic control unacceptable. • Choice of insulin formulations and/or should be individualised • The average daily insulin requirement is between 0. occult infections and other aggravating factors. insulin is recommended to be given after 10 p.0 GIK regimen (pre and intra-op) RPG > 11. Requirements in excess of this should prompt a search for an underlying cause such as non compliance. Biochemical confirmation. . (e. • Treatment should be individualised to the daily needs of the patient. . 4. then it can be given in the morning before breakfast. • In the BIDS regime.0 s/c insulin post-op .g. • In the young.5 to 1.0 Resume OHA post-op once GIK regime during op s/c insulin RPG < 11.Table 6: Management of Diabetes During Stress and Emergency Status of Control Minor Surgery Major Surgery Acceptable control Stop OHA Stop OHA FPG < 8. glucagon stimulation. In the event that insulin cannot be given after 10 p. Keep on insulin during stress and post-surgery until the stress is resolved and post- operatively until satisfactory wound healing. • Always be aware of episodic hypoglycaemia causing apparent poor diabetes control (Somogyi effect) to avoid aggravating the condition. thin diabetic patient. • All insulin treated patients must be encouraged to do self-monitoring of blood glucose. • The combination of oral hypoglycaemic agents (OHA) and insulin can be used in OHA failure.

Microvascular Microvascular complications associated with persistent hyperglycaemia: • Retinopathy • Neuropathy • Nephropathy 2.and Macrovascular • Diabetic Foot • Diabetic Dermopathy 5. • Diabetes Control & Complications Trial (DCCT) has shown that in type l diabetes (IDDM) microvascular complications can be delayed or prevented in up to 76% with good diabetic control. • Insidious in onset.3 EARLY DETECTION AND TREATMENT OF DIABETIC COMPLICATIONS • Early diagnosis and treatment can revert or delay. but may be present in up to 30% of type 2 diabetes (NIDDM) at diagnosis .g.2 TYPES OF COMPLICATIONS 1.1 INTRODUCTION • Chronic diabetic complications (macrovascular and/or microvascular) contribute significantly to morbidity and mortality in diabetes mellitus. . • Consider converting some patients back to OHA e. those well-controlled requiring small doses of insulin (<30 units/day) • In both obese and non-obese diabetic patients. Combination Micro. onset of complications such as nephropathy or neuropathy is not an indication to commence insulin injections MANAGEMENT OF CHRONIC DIABETIC COMPLICATIONS 5. Macrovascular Macrovascular complications are common in patient with diabetes and IGT: • Ischaemic heart disease • Cerebrovascular disease • Peripheral Vascular disease 3. complications but present treatment regimen cannot totally prevent these complications. • Studies have shown that complications are reversible if detected and treated early 5.

PREAMBLE Diabetic retinopathy includes dots and blots haemorrhage. • Fundal photography is useful where available. Regular checks to assess progress of complication should be made during follow-up visits. proliferative and diabetic maculopathy. RETINOPATHY 1. • Fluorescein Angiogram when indicated. • Type 2 diabetes patients should be screened for complications at diagnosis and type l diabetes patients at least 5 years after diagnosis and thereafter at yearly intervals. • Once a complication is diagnosed. Early laser treatment has been shown to be effective in arresting progression and prevent blindness. fibrosis and sudden blindness. . SCREENING • Ask for reduced visual acuity and blurring of vision. pre-proliferative. soft and hard exudates and new vessel formations. • Onset is insidious and patients do not usually complain until complications are far advanced. EDUCATION • Stress the important of regular eye check-up as retinopathy may be silent. 2. Usually classified as background retinopathy. • Fundoscopy Examination (Refer to guidelines Appendix 9). Any evidence of retinopathy or reduced visual acuity merits referral to ophthalmologist. ASSESSMENT PROCEDURES • Visual Acuity Test. These can cause retinal detachment. 4. 3. immediate and appropriate management must be given. • Visual acuity test (important for detecting maculopathy) • Fundoscopy at diagnosis and at yearly intervals.

• Blood pressure control. . • Laser photocoagulation therapy. TREATMENT OPTIONS • Blood glucose levels control.FIGURE 13 : DIABETIC RETINOPATHY 5.

is indicative of nephropathy. If positive. This is worsen by uncontrolled hypertension. MONITORING OF RETINOPATHY • Patients should be evaluated every 3 to 6 months when retinopathy detected or after laser therapy. EDUCATION Patient should be advised to have urine protein and blood pressure checked at regular intervals. SCREENING Blood pressure measurement at each visit. • 6. Ideally. Patients with established proteinuria invariably have retinopathy and must be examined. Microalbuminuria test at yearly intervals. This level is not detected by usual dipstick test for protein. 3. in the absence of other causes such as infection. Presence of proteinuria on routine testing. using dipsticks specific for microalbuminuria. Assessment of renal functions such as blood urea. • Note: Rapid control of blood glucose may transiently worsen retinopathy and may also cause transient changes in visual acuity. this should be assessed on a 24 hr urine collection but analysis of an early morning spot urine is an acceptable compromise. ASSESSMENT PROCEDURES • MICROALBUMINURIA Defined as an AER of 20-200ug/min. serum creatinine or creatinine clearance is not sensitive for the early diagnosis of diabetic nephropathy but indicated for monitoring of progression of this complication. PREAMBLE It is important to detect nephropathy early before overt proteinuria is present as early treatment may reverse or delay progression of nephropathy. especially in early stages. NEPHROPATHY 1. It is now established that there is positive correlation between proteinuria and cardiovascular morbidity and mortality. 4. • PROTEINURIA Ideally. 2. repeat test is required as excretion varies. it should be assessed on a 24-hr urine collection but an early morning spot .

assess: • microalbuminuria or proteinuria 6-12 monthly • Serum creatinine. urine is an acceptable compromise.8 g/kg body weight). Use of dipstick to detect proteinuria is acceptable for screening. MONITORING In established nephropathy. TREATMENT OPTIONS • Strict control of blood glucose and blood pressure. . Figure 14: Screening for Proteinuria 5. and BUSE at 6 monthly or more frequently when indicated.. • Moderate protein restriction (0. • ACE inhibitors • Renal dialysis • Transplantation 6.

• Position sense • Ankle jerk (reduced or lost) • Others. 2. • Examine for peripheral neuropathy especially sensory. autonomic neuropathy and diabetic myotrophy. TREATMENT OPTIONS • Strict diabetic control • Symptomatic treatment for pain and paresthesia. postprandial fullness. In males.. They should seek immediate medical attention to any injury or ulcer in the feet. warm skin. bounding pulse. autonomic neuropathy symptoms such as postural giddiness. EDUCATION Patients should be made aware of significance of numbness or paresthesia of feet/hands. Presence of peripheral neuropathy predisposes to diabetic foot problems. diarrhoea. abnormal sweating and impotence. . this include impotence. SCREENING • Ask about numbness of feet/hands. Others include mono-neuropathy. • Neurotrophic agents 6. Patients with long standing or poorly controlled diabetes should be made aware of the possibility of autonomic dysfunction. ASSESSMENT PROCEDURES Neurological assessment of lower limbs: • Touch and pin prick sensation • Vibration sense with 128 cycle tuning fork. 5. 3. MONITORING As per screening. 4. PREAMBLE Peripheral sensory neuropathy of lower limbs most common and usually the first to occur.NEUROPATHY 1.

DIABETIC FOOT 1. infection or gangrene. EDUCATION Foot care should be a standard module in diabetes education programme and must be intensive in high risk patients. Clinical features may include skin discoloration. ulceration or infection occurs. injury or ulceration to feet. PREAMBLE Foot problems are common in diabetes and are due to multiple factors including neuropathy. They are usually related to poor diabetes control. especially between the toes. gangrene and amputation. TREATMENT OPTIONS • Strict control of diabetes • Treatment for neuropathy • Specific and intensive foot care depending on severity from simple first aid for cuts and superficial infection to wound management in cases involving ulceration. • Examine the feet including for neuropathy) six monthly or at least yearly. must know how to take particular care of their feet and the need to seek urgent medical attention when injury. atrophy. angiopathy and dermopathy with poor foot care and hygiene. especially those with established neuropathy. Monitoring of Diabetic Foot • Assess patient's foot care habits • Foot examination at every follow-up (refer Appendix 10) . 2. 3. cutting their toenails. 4. foot u1ceration. infection. Patients. They must be taught daily foot inspection. trimming calluses and corns. improper foot wear and poor joint mobility. SCREENING • Ask regarding symptoms of peripheral neuropathy. as well as foot deformity (Charcot's joint). proper techniques of washing and drying their feet. Refer to appropriate specialist when indicated 6. ulceration and gangrene. ASSESSMENT PROCEDURES Foot Examination (See Appendix 10) 5. The high morbidity and mortality is related to.

• 3. HDL and LDL-cholesterol and HDL-LDL ratio. 4. • Stop smoking. especially in women and those with proteinuria (even at the stage of microalbuminuria).MACROVASCULAR COMPLICATIONS 1. WHR . • Doppler study (if available). total cholesterol. cerebrovascular and peripheral vascular diseases.see Appendix 11) • Blood Pressure and all peripheral pulses including carotids. dyslipidaemia (increased triglycerides and LDL-cholesterol with low HDL-cholesterol). • Advice on diet for weight control and hyperlipidaemia. • Ask for symptoms of macrovascular complications. WHR Blood Pressure • Fasting lipids including triglycerides. ASSESSMENT PROCEDURES • Assessment of obesity (BMI. • Encourage self monitoring eg. • ECG (stress ECG when indicated) . • Regular exercise. They include coronary artery. 2. PREAMBLE In diabetes (including those with IGT macrovascular complications are are common because of accelerated atherosclerosis. Risk factors include smoking. hypertension. obesity and positive family history. blood pressure and blood glucose. Therefore it is important to identify or aggressively treat cardiovascular risk factors where possible. EDUCATION • Educate patient on the need to check and control modifiable risk factors regularly. Risk of cardiovascular morbidity and mortality is higher in diabetic . • ECG (stress ECG when indicated) • Echocardiograms (if available). SCREENING Patients should be screened for risk factors. risk factors • Examine BMI.

• Exercise. • Assess risk factor parameters (refer Appendices 12 and 13). • Control of modifiable risk factors. To treat if persistent after adequate attempt is made to control diabetes (to check). MONITORING OF MACRO VASCULAR COMPLICATIONS At regular follow-up (3-6 monthly) • Monitor for symptoms related to macrovascular disease. Stop smoking. • Doppler study (if available) 5. Blood pressure: Use of ACE inhibitors preferable especially in those with concomitant microalbuminuria. • Aspirin and other anti-platelet agents 6. . CXR and Doppler studies should should be done at least annually • Review smoking habit. • Dyslipidaemia. The ECG. exercise and diet compliance. TREATMENT OPTIONS • Strict control of blood glucose (avoid hypoglycaemia) • Diet.

Hyperlipidaemia: Total cholesterol >6.0 kg or more .3 mmol/l Symptoms of Diabetes: Polyuria Polydipsia Polyphagia Lethargy / Tiredness Pruritus vulvae Balanitis Weight loss Family History: Natural parents and/or siblings Gestational Diabetes: Diabetes first diagnosed during that particular pregnancy History of big baby: Birth weight > 4.5 mmol/l and/or fasting triglyceride > 2.APPENDIX 1 Definition of Terminology Obese: BMI >30 BMI based on formula BMI = Weight (kg) / Height (m)2 Hypertension: BP >140/85 mmHg on 3 different occasion with/without treatment.

16 hours. The blood should be collected in a tube containing sodium fluoride (6 mg per ml of whole blood) and centrifuged to separate plasma. Freeze plasma for glucose for estimation unless it can be done immediately. during which patient may drink plain water. . For interpretation refer Appendix 5.APPENDIX 2 Procedure for Fasting Plasma Glucose (FPG) Testing for Fasting Plasma Glucose should be preceded by an overnight fast of 10 .

75 g of glucose per kg of body weight up to a total of 75 g of glucose. International Study Group for Diabetes Bulletin. Note: For children. Blood samples must be collected 2 hours after the glucose test load.g. Unless the glucose concentration can be determined immediately. 2: 23-26) . the blood samples should be collected in sodium fluoride a tubes (6 mg per ml of whole blood) and centrifuged to separate the plasma.300 ml of water over 5 minutes. the test load should be 1.APPENDIX 3 Procedure for Oral Glucose Tolerance Test (OGTT) The OGTT should be done in the morning after at least 3 days of normal diet (more than 150 g of carbohydrate daily) and usual physical activity. inactivity. 1978. The International Study Group for Diabetes in Children has recommended a test load for children of 45 g/m2 body surface area (Weber B. The presence of factors that influence interpretation of the results of the test must be recorded (e. Smoking is not permitted during the test. refer to Appendix 5. the subject is required to drink 75 g of anhydrous glucose in 250 . infection) After collection of the fasting blood sample. For interpretation of results. medication.16 hours during which plain water may be allowed. The plasma should be frozen until the glucose concentration can be estimated. Use glucose oxidase or hexokinase method for glucose assay. The test should be preceded by an overnight fast of 10 . Standardization of the Oral Glucose Tolerance Test.

insert strip Prick finger using disposable lancet Wipe off first drop of blood Press gently to ensure adequate drop of blood is formed Follow instruction manual for individual meter for further step Read and record reading NB: Use of glucose meters is not acceptable for diagnosis but can be used for screening.APPENDIX 4 Procedure for use of glucose meter Get ready equipment Calibrate as per instruction Inform patient of procedure Clean tip of finger with alcohol swab ( allow finger to dry ) Switch on meter. .

8 > 7. mmol/l WHOLE BLOOD PLASMA Venous Capillary Venous Capillary Diabetes mellitus · Fasting value > 6.12.7 > 6.300 ml of water for adults and 1.8 > 7.8 · Two hrs after > 10. Geneva.9 .7 .1 > 11.APPENDIX 5 Diagnostic values for the oral glucose tolerance test (OGTT) .1 7.2 · Two hrs after glucose load For epidemiological or population purposes.8 · Fasting value 6. for children) may be used alone or with fasting value.10.0 7. the 2 hour value determined by specific enzyme-assay after an oral glucose load (75 g in 250 . WHO 1985 .8 .7 > 6.7 > 7.2 glucose load Impaired glucose tolerance > 6.8 .75g/kg of body weight. Source: Diabetes Mellitus: Report of a World Health Organization Study Group.0 > 11.1 > 12. The fasting value alone is considered less reliable since true fasting cannot be assured and spurious diagnosis of diabetes may more readily occur.7 > 7.11. up to maximum of 75g.WHO Criteria Glucose Concentration.11.1 8.

Quality Assurance • Internal Quality Assurance include regular calibration of glucose meter . Training of Personnel (Care Providers) Category of personnel to be trained • Doctors • Medical Assistant • Staff Nurse / Public Health Nurse • Community Nurse (JD) Scope of training • Introduction • Epidemiology • Conduct and interpretation of test • Risk assessment • History taking • BMI • Symptoms of diabetes • NIDDM Practise Guidelines 3. Gauze.APPENDIX 7 IMPLEMENTATION OF DIABETES CARE PROGRAM 1. Prevalence study every 5 years (sentinel survey) ii. Monitoring of selected samples from selected health clinics iii. Alcohol 2. Equipments Required • Glucose meter • Dipstick strips • Glucose test strips • Ophthalmoscope • Weighing machine • Snellen’s Chart • Height scale • Sphygmomanometer • lancets for finger pricking • Cotton. Monitoring and Evaluation by Diabetes Care Providers i.

• External Quality Assurance use 1 in 20 samples to be tested (venous blood) in accredited reference Laboratory for validation • Utilise Laboratory (External Quality Assurance Scheme) .

11. No: Ethnic Group: Weight: Date: Height Yes No BMI: >30 Symptoms of diabetes Polyuria Polydipsia Polyphagia Lethargy / Tiredness Weight loss Pruritus vulvae / Balanitis Definite Hypertension Hyperlipidaemia History of Gestational Diabetes History of big baby (Birth Weight >/ 4.0 .APPENDIX 8 CHECKLIST FOR SCREENING OF DIABETES MELLITUS AT PRIMARY CARE LEVEL Name : Date of Birth : I/C.0 mmol/l (Suspected) > 11.0 kg) Family history of diabetes Screening : RBS mmol/L < 7.0 mmol/l (Diabetes) Recommendation APPENDIX 9 VISUAL ACUITY AND FUNDOSCOPY EXAMINATION .0 mmol/ (Normal) 7.

A preliminary eye examination should include: Distance visual acuity testing. Examine the quadrants carefully. and the appearance of the retinal vessels. there will be a large crescentic shadow on the nasal side of the iris. the lens (i. Examine of the fundus through the dilated pupil using a direct ophthalmoscope. Gradually move the ophthalmoscope forward until the structures in the anterior part of the eye come into focus. Assessment of the anterior chamber depth. Illuminate the red reflex of the fundus. If the anterior chamber depth is normal. If the anterior chamber depth is slightly shallow there will be a slight shadow on the nasal side. Near vision or reading acuity with the patient‘s corrected reading glasses. it is sensible to develop a technique that enables all parts of the fundus to be checked. These 2 areas should be examined last as they excite the greatest pupillary constriction. using torchlight. Hold the ophthalmoscope some 8-10 inches from the eye. using a near vision chart. based on the following finding. tested at 6 m. using a Snellen’s or E chart for the illiterate. Gradually reduced the number on the ophthalmoscope lenses and at the same time approach the eye until the retina come into focus. The technique of ocular examination is as follows: Adjust to + 10 on the lens slide of the direct ophthalmoscope. Acute glaucoma may be precipitated by pupillary dilatation if the anterior chamber is very shallow. . and the entire iris is illuminated. If the anterior chamber is very shallow. It is important to tell the patient to return if they feel any pain or discomfort some hours after the pupillary dilatation. in the following order: Start with the optic disc. as it is here that new vessels are most likely to be found. Finally examine the areas temporal to the macula and then the macula itself. Dilate the pupil using Tropicamide (Mydriacyl) 1% eye drops.e. If the patient failed to achieve normal vision with the best corrected distance glasses. The illuminating light is aimed horizontally across the surface of the anterior chamber from one limbus to another. # When examining the retina. defect. looking for any possible cupping. Pay particular attention to the appearance of the retina adjacent to the veins. Any defect that is lying in the cornea. cataract) or the vitreous will cause a darkening of the red reflex. pinhole acuity should be measured.

APPENDIX 10 EXAMINATION OF THE FOOT .

bouncing pedal pulses - warm dusky pink colour. foot drop. PATIENT QUESTIONNAIRE POINTS* 1 Are your legs or feet numb? Yes [ ] No [ ] 2 Do you ever have any burning pain in your Yes [ ] No [ ] legs or feet? 3 Do you ever have any pricking feelings in Yes [ ] No [ ] your legs or feet? 4 Do you get muscle cramp in your legs or feet? Yes [ ] No [ ] 5 Do your legs hurt when you walk? Yes [ ] No [ ] 6 Are you able to sense your feet when you Yes [ ] No [ ] . C & ST. etc.Parameter Clinical Examination Objective Testing Skin Visual inspection: lesions. absent tendon reflexes. Vascular leg and foot pulses Non-invasive rubor/pallor Doppler Studies venous/capillary filling time skin temperature Deformity toes and foot deformities Radiographs prominent metatarsal heads Charcot joints SCREENING AND EARLY DETECTION OF FOOT PROBLEM Name : ___________________________ Age : ____________________ Duration of Diabetes : _________Yrs *1 point for Yes and 0 for No A. ulcers. Sensory pinprick sensation light touch vibration heat and cold sensation proprioception Motor Intrinsic muscle wasting. fungal interdigital maceration. calluses scars. nails. fissuring distended dorsal veins. Electro-physiological test weakness. Autonomic Decrease sweating and cause dryness.

g. C:NEUROLOGICAL EXAMINATION Light touch Pin Prick Knee Reflex Ankle Reflex Total Score /12 R L Total Normal=0 diminished=1 absent=2 normal=0 D:VASCULAR EXAMINATION Femoral Popliteal Dorsalis Tibialis Total Score /12 . Yes( ) No( ) Yes( ) No( ) claw toe/hammer toe/carus feet 7 Past ulcer/present ulcer Yes( ) No( ) Yes( ) No( ) 8 Previous amputation Yes( ) No( ) Yes( ) No( ) Total /8pts /8 pts Note : Total score for physical examination is 16 points. walk? 7 Are your symptoms worse at night? Yes [ ] No [ ] TOTAL /7 CLINICAL EVALUATION PHYSICAL EXAMINATION (R) (L) Right leg & foot Left leg & Foot To detect signs of high risk foot points points 1 Dry skin Yes( ) No( ) Yes( ) No( ) 2 Callus/ corns Yes( ) No( ) Yes( ) No( ) 3 Fissure Yes( ) No( ) Yes( ) No( ) 4 Skin changes (shinning skin/hair Yes( ) No( ) Yes( ) No( ) lost) 5 Nail deformities/colon Yes( ) No( ) Yes( ) No( ) 6 Abnormal shape/deformed e.

Loss of protective sensation Examine feet at every visit. stop smoking. Examine feet at every visit Prescription foot ware Refer specialist if necessary Risk Score Score Status 0 Foot not at risk 1–3 Foot at risk Neurological examination > 3 Loss of protective sensation Vascular examination > 3 points Poor circulation APPENDIX 11 1. Loss of protective sensation with high Examine feet at every visit.g. No loss of protective sensation Annual check-up. Risk category 2 Foot care education a must.g. Risk factor education e.R L Total Normal=0 dismished=1 absent=2 E:HbA1 Risk and Management Category Risk Category Management Option Risk category 0 Patient education. Risk category 1 Foot care education a must. stop smoking Risk category 3 Foot care education a must Loss of protective sensation history of plantar Risk factor education ulcer. pressure (callus/deformity) or pour Prescription foot ware circulation Risk factor education e. BODY MASS INDEX (BMI) BMI = Weight (kg) / Height (m) x Height (m) .

The healthy range for BMI is 18.5 Under weight 18.95 APPENDIX 12 Clinical Monitoring Protocol Name :_________________________________Sex :________________________ . obtain BMI by referring to BMI Chart.less than 30 over weight ≥30 Obese BMI applicable for adults aged 18 .5 .5 – 25 BMI Less than 18.64 years. Remove shoes. 2.85 Male < 0.less than 25 healthy weight 25 . WAIST HIP RATIO (WHR) Measure waist at its narrowest or measure waist at the navel (umbilical level) Measure hips at its widest. Wear light clothing. Healthy Waist Hip Ratio: - Female < 0.Alternatively.

supine -standing Feet . must elicit symptoms of complications and symptoms of risk factors Education At every visit emphasise on: A. Fructosamine AT INITIAL AND ANNUAL VISIT Visual acuity Fundoscopy Heart . Good diabetic control Diet Drug compliance Foot care Weight control Self monitoring B. (new): ________________________ Ethnic Group : _______________ Height: ____________________m History At each visit.Neuropathy -Pulses -Ulcer Fasting / 2 hr post meal BS HbA1c (%) Sr.Date of Birth :___________________________ Age : _______________________ NRIC No. Prevention and Control of Complication AT INITIAL AND AT EACH VISIT Examination\Date Weight (kg) BMI WHR BP .

Creatinine Total Cholesterol LDL Cholesterol HDL Cholesterol Triglyceride TChol / HDL Ratio WHEN INDICATED Echocardiogram Stress test Doppler studies CXR Notes: When complications have been diagnosed appropriate examination and investigations are done at more frequent intervals.ECG Urine for Protein Microalbuminuria BUSE Sr. APPENDIX 13 Biochemical Monitoring Methods and frequency of self monitoring depend on the goals and mode of treatment Self Monitoring .

It is mandatory for diabetic women during pregnancy. It is the only way to confirm hypoglycaemia Timing Mode of Breakfast Lunch Dinner Treatment Pre Pre Post Pre Post/Pre bed Diet Only √ √ √ √ √ OHA √ √ √ √ √ Insulin √ √ √ √ √ Frequency The frequency of testing depends on the stability of glycaemic control Poorly controlled / unstable At least once daily Adjust treatment accordingly Well controlled / stable Once or twice weekly 2. Urine glucose self-monitoring It is useful in detecting major hyperglycaemic swings It is NOT useful if renal threshold is HIGH or LOW The test should be performed on a double voided specimen Timing Fasting and Post meals Frequency 1-2 times weekly Caution Urine glucose monitoring is UNABLE to confirm/warn against hypoglycaemia Targets for Control 1.1. Home Blood Glucose Monitoring Blood glucose testing is the method of choice in monitoring glycaemic control It is desirable for patients on oral hypoglycaemic agents and is strongly advised for patients on insulin. Target Blood Glucose Levels Glucose Levels (mmol/L) Timing Ideal* Acceptable Poor .

8 >7.9 >3. Other targets for control Ideal Acceptable Poor HbA1c % Within 1.9 <0.3 3.5% Within 2% > 2% points of points of upper points of upper upper limit of limit of normal limit of normal normal Fructosamine Please refer to literature enclosed with the assay kit Lipids Total cholesterol mmol/L < 5.8 Two hr postprandial 4.7 <2.2 5.5 HDL-cholesterol mmol/L >1.Prebreakfast 3.4-10.5 >6.3 Body mass index kg/m2 Males < 25 ≥ 27 > 27 Females < 24 ≥ 26 > 26 Blood Pressure mmHg ≥ 130/85 ≥ 160/95 > 160/95 .3 >2.9 *Ideal levels are similar to those seen in non-diabetic individuals and are recommended for the pregnant type 2 DM (NIDDM) 2.1 >0.5-5.7 4.9-7.4-6.8 Preprandial 3.9-7.5-5.0 0200-0400 Hrs >3.2-6.8 3.9 Fasting triglycerides mmol/L <1.0 >10.8 >7.